A New Method for Patent Foramen Ovale Closure: Delivering Sheath Over Coronary Sinus Catheter into Left Atrium

139 Copyright © 2013 The Korean Society of Cardiology

Korean Circulation Journal

Introduction

Patent foramen ovale (PFO) is the persistence of the normal fetal communication between the right and left atria. It is a common benign condition; up to 27% of the population has PFO.

But un- der certain hemodynamic circumstances, PFOs can open and act as a conduit for thrombi to pass from the systemic venous circulation to the systemic arterial circulation, predisposing to stroke and par- adoxical embolism.

Herein, we describe a new method in device closure of PFO, introduction of delivery sheath over coronary sinus catheter into the left atrium in a challenging case.

Case

A 34-year-old female with cryptogenic stroke was admitted to our hospital. On a physical examination, she had left paraplegia. Her electrocardiography was in sinus rhythm. Transthoracic echocardio-

Case Report

http://dx.doi.org/10.4070/kcj.2013.43.2.139 Print ISSN 1738-5520 • On-line ISSN 1738-5555

A New Method for Patent Foramen Ovale Closure: Delivering Sheath Over Coronary Sinus Catheter into Left Atrium

Tayyar Gökdeniz, MD, Ahmet Çag˘rı Aykan, MD, S˛ükrü Çelik, MD, and Faruk Boyacı, MD

Department of Cardiology, Ahi Evren Chest and Cardiovascular Surgery Education and Research Hospital, Trabzon, Turkey

Patent foramen ovale (PFO) is a frequent condition. It usually does not pose any threat to life, but in certain circumstances, it can open and serve as a conduit for thrombi causing paradoxical embolism. Herein, we report a case of PFO in a patient with ischemic cerebrovascular accident, due to paradoxical embolism, which could not be passed via general practice; hence it was crossed with coronary sinus catheter, through which the delivery sheath was placed into the left atrium, and it was successfully closed. (Korean Circ J 2013;43:139-141) KEY WORDS: Foramen ovale, patent; Amplatzer septal occluder; Coronary sinus catheter.

Received: February 4, 2012 Revision Received: April 17, 2012 Accepted: June 21 2012

Correspondence: Ahmet Çag˘rı Aykan, MD, Department of Cardiology, Ahi Evren Chest and Cardiovascular Surgery Education and Research Hospital, Sog˘uksu Mah. Çamlık Cad. 61040 Trabzon, Turkey

Tel: 905058689461, Fax: 904622310483 E-mail: [email protected]

• The authors have no financial conflicts of interest.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.

org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

graphy was normal, except interatrial septal aneurysm. Thus, tran- seosaphageal echocardiography was performed, which revealed in- teratrial septal aneurysm and PFO (Fig. 1). Hence, percutaneous clo- sure of PFO, under general anesthesia with the guidance of trans- esophageal echocardiography (TEE), was planned. A 7 Fr sheath was introduced through the right femoral vein, and 80 U/kg of unfrac- tioned heparin was administered, intravenously. PFO was attempted to cross unsuccessfully with multipurpose, right Judkins, and right Amplatz diagnostic catheters. After a right atrium angiography, we crossed PFO with coronary sinus catheter to assess the reference en- try point, and then another 7 Fr catheter was inserted to the left fe- moral vein and tried to cross PFO with Multipurpose, right Judkins and Amplatz diagnostic catheters over normal and hydrophilic guide wires under the guidance of coronary sinus catheter, but could not passed through PFO. Thus, we pulled the catheters and inserted 9 Fr delivery sheath from the left femoral vein, then inserted 7 Fr coro- nary sinus catheter through the delivery sheath and crossed PFO with coronary sinus catheter (Figs. 1A and 2A), and deployed the delivery sheath over coronary sinus catheter into the left atrium, and pulled back the coronary sinus catheter and inserted the Amplatzer PFO occluder through the delivery sheath, successfully deploying the occluder (Figs. 1B and 2B). The patient was discharged uneventfully with aspirin 100 mg and clopidogrel 75 mg per/day medication.

Discussion

Patent foramen ovale closure is performed in a standard catheter-

ization laboratory, under physiological monitoring and fluoroscopic

guidance. TEE examination is complementary for optimal results.

140 A New Method for Patent Foramen Ovale Closure

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General anesthesia is required for TEE guided procedures. Procedure was performed through the femoral venous access, and intrave- nous unfractioned heparin 80-100 U/kg was administered. The multipurpose diagnostic catheter is commonly used to cross PFO, but in unsuccessful cases, the right Judkins and Amplatz diagnostic catheters may be used. Right atrial angiography may be performed in challenging cases to understand the atrial anatomy. PFO is fre- quently crossed with coronary sinus catheter and radiofrequency ablation catheters, during electrophysiological studies. In laborato- ries that are familiar with electrophysiology procedures, coronary si- nus catheter may be used for the localization of PFO; furthermore, it may be used for crossing PFO in order to deploy the delivery sh- eath into left atrium, for saving time in prolonged cases, in different

atrial anatomy and when usage of classical maneuvers and cathe- ters are unsuccessful.

Moreover, blade septostomy may also be used when classical methods failed, but it is associated with major complications, in- cluding cardiac perforation, vascular injury and conduction distur- bances. But crossing the PFO, with coronary sinus catheter, is safe- ly used electrophysiology procedures.

In conclusion, this promising method, deploying the delivery sh- eath over coronary sinus catheter, may be used easily and safely when routine maneuvers fail.

References

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A   B  

Fig. 1. The transesophageal echocardiographic imaging of patent foramen ovale. A: arrow shows the bulging of interatrial septum to the left atrium which indicates atrial septal aneurysm. B: color Doppler transesophageal echocardiography examination showed passage of flow through a slit like patent fora- men ovale from right atrium to the left atrium.

A   B  

Fig. 2. The angiographic views during the crossing of PFA and after the successful deployment of PFO occluder. A: insertion of 9 Fr delivery sheath over 7

Fr coronary sinus catheter through PFO into the left atrium was demonstrated. B: successful deployment of Amplatzer PFO occluder was shown. PFO: pat-

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141 Tayyar Gökdeniz, et al.

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